Tympanoplasty (Revision)

CHAPTER 1

This patient is a 61-year-old female who presents today for repair of a left-sided tympanic membrane perforation. This is a revision tympanoplasty. She has had two prior tympanoplasties - one was successful and she subsequently developed a traumatic perforation of that ear after her original successful surgery. And then she underwent repair of the new perforation, which has failed. She has a pretty large anterior marginal perforation so it extends all the way to the level of the annulus and and so our goal today is to try to reconstruct the eardrum using a lateral graft-type tympanoplasty.

CHAPTER 2

You can see she's had a previous postauricular incision here. Prior to her tympanoplasty surgeries, she also very early on underwent a mastoidectomy on this side. I'm not sure the - the reason this was originally done, it may have been due for - done in conjunction with one of her original tympanoplasties to help improve either healing or ventilation, but I do not have those records. So we will infiltrate behind the ear - this is 1% lidocaine with 1 to 100,000 epinephrine. We're going to reuse her original incision line. And as I'm injecting, as I get closer to the inferior aspect of this incision I'm going to feel the tip of the mastoid, so I don't pass the tip. You want to avoid getting too much local anesthetic inferior to the tip of the mastoid, and just to prevent anesthesia of the facial nerve. Okay. And a sponge, please? Can I also have two folded towels? And then we're going to need a bulb irrigator in just a moment. Now - suction.

So we'll start also by rinsing the ear canal very well, just to dilute out any bacteria that may be in the canal. We typically prep with Chloraprep around the ear, but do not allow the Chloraprep to get down in the ear canal. I don't use any particular prep in the ear canal itself such as Betadine, I just rinse it very well with sterile saline or lactated Ringer. Can I get one more of these, please? Yeah, I think it's just - you'll see in a moment, she has a lot of - mucositis, like the epithelium even of the canal has become mucosalized, and it's just wet and then I think this - you just get this sort of desquamating skin here. Fortunately, the anterior canal wall skin looks still pretty good, but she - her perforation has really become kind of a total perforation, but it's - I don't know whether it's from moisture - I believe - she has been wearing a hearing aid in this ear intermittently, and I think that probably the moisture from the hearing aid, and maybe just from normal day-to-day activities. Her ear's pretty inflamed looking. I mean this is all granulation tissue here. Table away, please. Oh, absolutely. So cotton ball and Vaseline. Intermittently, she did need some drops. Table away, please. But - okay, so you can see she has a pretty large perforation. Can I have a Rosen elevator? A Rosen needle?

So it really is, it's basically a total perforation. So, this is the promontory bone right here that you can actually see the - the tip of the incus and the stapes right here. That's where the IS joint is. This is the malleus handle coming down. It's kind of become ad- well it's not adhesed, but it's - the tip of the malleus, so this is a large subtotal perforation that comes around. Small amount of drum left here, the annulus up top here, but all of this is mucosalized, it just - and I think it's just chronic from chronic discharge from the ear. So I will probably use pretty good cartilage grafts to try to reconstruct it. Can we have the canal injection now? But I mean I don't see - I think this is a case where we have to kind of do a lateral graft technique. I don't know if there's much left we could... We're at 2 there. Okay. Now the injection. So we're going to, we're... Oh yeah, hold that for a second, Chelsea.

So we're going to start with our canal injection now, This is a 4-quadrant canal injection. We start just inside the meatus, just a little bit lateral to where the bony cartilaginous Junction is in this hair-bearing sort of softer tissue and we'll allow this just to sort of plump up as we inject. And we kind of march around the entire ear canal. And it's just injecting circumferentially, into that meatal soft tissue. And this is - exactly, this is 1% lidocaine with 1:40,000 epinephrine. Okay, and then - Do you have one size larger speculum, a number 7? So next... Then we'll use a little bit larger speculum. And as I kind of push this in and dilate the ear canal, it also pushes that local anesthetic down into the canal. Suction? And injection back, table towards me, please. And... I'm going to go right in, just beyond that bony cartilaginous junction until I hit bone, and then just slowly infiltrate this. She has kind of a little bit of a depression in the back part of her ear canal wall here, which kind of makes injecting that a little bit tricky. Yeah, I don't think it's in her - but you can see, right back here, the - bony canal wall, there's like a little depression right there, and I don't know if it's because this cartilage portion of the ear canal kind of comes forward a little bit, you know, maybe with all her revision surgeries, the way that it has healed. But you do sometimes see that. Okay, hold that. Now can I go to a 3 suction, and next we're going to make vascular strip incisions.

CHAPTER 3

And you can see the stapedial tendon, right down here, that little white area, but all this is - this is all mucosalized, so not, not the healthiest of tissues, unfortunately. Can I have a number 1 knife now? And so I'm going to start up here, right at the - above this, this is the area of the pars flaccida right here, and so we're going to come a little bit lateral to that, right down on the bone and come straight up through. 2, 3, and then that's our incision along the tympanosquamous suture line, and then we come down to the approximate level of the tympanomastoid suture line in a similar incision. Now I need a 6400 blade. And then with a 64, which is a beaver blade, and just a thicker bl- come through this cartilage ring of the meatus, and we want to kind of feel it as it goes along the bone and rolls over the outer edge of the bony ear canal here, so we want to bring that incision all the way out laterally, and then up here at 12:00, the same thing. And this is going to allow us to really get that vascular strip freed up and back behind the ear. Okay. Now can I have a 15 blade, and the overhead? So now we'll go back to our postauricular incision. Can I have a sponge, please?

CHAPTER 4

We'll use her original incision. Can I have a self-retaining retractor now, large? And now a 15 back, please? And the issue is she's had 3 previous tympanoplasties. I don't think she really has too much in the way of fascia left, so we are actually going to us a - connective tissue collagen graft, which is harvested from porcine intestinal submucosa. This is a premade graft today instead of using her own tissue. Can I have a Bovie, please? So now I'm going to feel along the temporal line, where the root of the zygoma is and we'll make a horizontal cut along that line right down to the bone for the mastoid muscle periosteal layer, and then connect that with a vertical cut to create - a 7-flap here. Now a periosteal elevator? A Lempert? Thank you. No, this is good. And there is her previous drilled mastoid. Yeah, I'm not sure why her original - She originally had this mastoid out, I suspect it was just to help improve maybe healing if - she doesn't have a history of cholesteatoma or anything like that. Pickups, please? We are going to reposition our retractor here. Okay. I see one issue. All right, now. Can I have a... Oh, it's been lowered quite a bit too. Can I have a number 3 suction? So one issue she has when we look at the - the mastoid in the posterior canal wall is that overtime it looks like the - her canal wall, she may have gotten some loss of bone here, and the height of the canal wall is lower than than what we would typically expect, and that probably accounts for why she has that little bit of a depression in the posterior canal wall when we were on the canal side. Can I have a Freer, please? A Freer? Yeah. Can I have a bipolar? Yeah, I think so, this is a little bit of a - this will be... What's the bipolar on guys? We got the 40 on that? Can you go to 40? Okay. Okay, now the - take that. Yeah, you got it. And so now with our Freer, which is the - sharper end here, we're going to carefully elevate this posterior canal wall skin. And I definitely... Yeah, I definitely don't want to tear this, because we need to be able - we need this flap long enough that it will cover over this area. And she's got quite a bit of - I think this is more of just a chronic, maybe from chronic inflammation, but there has definitely been resorption of pretty good area of bone right here. Right, it's very common a lot of times - early on, when we're, when you're learning how to do mastoids surgery, and you're doing in tactile approaches as you come around this corner here, the drill has a tendency if you're not careful to roll forward and you start to take away some of this bone. And I'm going to have to think about that. We may have to actually try to repair that with a little bit of cartilage, because that is - she's lost - yeah, here's the height of the mastoid, here and here. There's almost a segment missing right there. Right. Simple cartilage has a really nice curvature that approximates the curvature of the ear canal. So it is really quite a good material to use. So here's our inferior vascular strip incision, we've identified that. We want to also find the superior one. And keep elevating here. Can I have a pair of - can I have a 5910? For the 5910, I want to sharply come across this. I don't want to tear this vascular strip. So I am going to come in, there's my superior incision, and at this level, I'm going to just come right across here, sharply so as not to actually tear it, and have it become shortened. Okay, so here's my vascular strip. A pair of smooth forceps, please? Yeah, I don't know, that's pretty strange. And again, I think - I think she, one issue is she's had a lot of just chronic inflammatory issues with this ear, to the point that at times wondered if she has some underlying immune issue. Suction? But certainly the ear today continues to look pretty inflamed, and she has all this mucosalization of the skin, and then this resorption of bone here. Okay, pull on the ear, pull the ear forward, please. And then we're going to reposition this, so that so it protects our vascular strip. All right, suction? And then a bipolar? Oh, that is kind of - It is kind of a defect there. Okay, bipolar? And there is the body of the incus, right here that we see if we gently tap on that you see movement of the ossicular chain. I mean, she's lost almost a good close to 50% of the bone here. Well, that is a thought, you could do that. She looks like she's got some cartilage or something banked in the back here. Yeah. I don't think we'll use that. Just set that aside, please. Okay, next I need a 6400 blade. And we're going to come pretty far out laterally, right just up at the junction of the hair-bearing and non-hair-bearing skin we'll make an incision.

CHAPTER 5

Coming around. Yep. And that comes all the way around and meets up with where our previous fascia strip incision is - what we want to do... This is standard for doing a lateral graft-type technique. We need to remove this anterior canal wall skin and actually, if we need to drill the canal wall, we will do that. She probably doesn't need a whole lot of bone removal just because she's had prior lateral graft tympanoplasty, but this helps facilitate placement of our graft later and coverage of that graft. So as I'm dissecting here, I'm trying to get down to bone. Some of this incision is coming through some of the cartilage, so I'm just kind of dissecting out some of that cartilage, getting down to the bony anterior canal wall. So that's what we're doing here, and now we're kind of down to bone. Once I'm down to bone, then we'll use an elevator to kind of elevate this skin very carefully. Now, from her history of her last surgery, she does have a dehiscence in the bone overlying the temporomandibular joint, so we'll have to be very careful as we're dissecting this skin not to tear at that point because sometimes it's fairly adherant to the underlying periosteum. Large, round knife. Can I have table away, please? Okay. Is this the large? It definitely is? Okay. This actually, yep, so here, as we're elevating, we want to kind of suction behind the large - the round knife, just to avoid sucking on the skin too much. And I'm going to elevate this all the way down to the level of the annulus. Here's where it feels like it's probably dehiscent, and so we may have to kind of come back and sharply dissect some of that off. The short process of the malleus is right about here, underneath us. And so then we'll just gently kind of keep dissecting the skin off of that area. And then come inferiorly, same thing, slowly working down. The reason for this if this were the first time she were having a tympanoplasty - normally the anterior canal wall juts out fairly far, there's often a quite a big bend in the canal due to the prominence of the anterior canal wall overlying the temporomandibular joint, and so you - When you do lateral grafting you have to remove some of that overhang to create more of an open angle between the eardrum and the ear canal wall. So I'm continuing to dissect down until we get to about the level of the annulus, and she may have some dehiscence of her annulus as we get down here. And I can feel... Yeah, as I'm - as I'm elevating I keep pushing down, and then it kind of stops almost like I'm hitting a ledge, which is the area of the annulus. Table away. Now the one issue - the difficult thing with her is I can feel here is where she has this dehiscence. Keep going. Thank you. And this is where it's going to be a bit of a challenge because we need to get the skin off, but it doesn't separate quite as easy - as it does coming off a bone, clearly. So, I'm going to try to almost sort of scrape it here. Now there it goes. Unless we get a whole one out, which we did. Can I have a 1 knife, please? The other problem is she has all this mucosalization, which makes this tissue quite sort of flimsy and not so healthy. You know, when it's all mucosalized like this, it's just very friable, and tears quite easy. There is the tip of the malleus. We really need to kind of elevate all this too. Chorda is under here. It's interesting, her ear was not nearly this - inflamed in the past. Okay, a wipe, please? And we're going to keep elevating gently here. That's the malleus handle. Yeah, it's just there's not a great plane, unfortunately. Do you have a pair of cups? Sometimes you can actually peel it away. Sometimes it actually peels quite nicely. Again, here's the tips of the malleus. Probably come through that a little bit more sharply. Okay, I have a 5910. That was her chorda. Chorda tympani nerve is right here. So we are now freed up from there, and then just kind of dissecting. This is probably some remnants of her prior graft material, tucked up under the malleus there. So we want to try to clean off as much of this old graft material as we can. Sharply dissecting that. Now back to a small weapon, please? Okay, there's a small hole there. And this makes it challenging. That skin does not want to come away that easy. Very slowly kind of pushing and dissecting the skin off of the underlying periosteum - it is definitely more challenging when there is a dehiscence like this. Dissecting this down. Try to free this up from the malleus now. There we go. Now we are freed up from the malleus. The problem is the annulus is going to be a bit of a challenge figuring out where that is. Our other option would be... To try to do an underlay graft here, but... It's not a bad idea. The question is will this mucosalized tissue heal. That and I'm - you know, I think - I'm having a - this is going to be - this is really getting difficult to try to sep- it's not separating real well from this periosteum, and I don't think I'm going to be able to do that without tearing a lot up - a lot of this skin, so what we may do is do a big - do an underlay, and put it underneath this, tuck it way up under here. I think that actually might be the best option in this case. Normally, I would prefer to do a lateral graft-type. My only concern is this is all mucosalized, and there's always a concern, is this going to - will it epithelialize properly or not? Right. You mean if I did a lateral graft? Well if you do a lateral graft you're basically taking all this mucosalized tissue out, and so I think, you know, you're starting with healthier tissue, but I just... This is not coming out real well. Let's have a pair of Bellucci scissors, and I think maybe doing it medial is probably going to be the best option. So a little change in plan here. Let's have a pair of Bellucci's to the left. Yes, please. Kind of like a - maybe kind of like a little bit of a hybrid procedure here. I do notice that she's got a little epithelial pearl. Can I have a sharp medium foot plate hook, white? Yeah, she has a little small pearl right there, don't know if you can see that. Yeah, probably just from one of her prior surgeries, and she got an adhesion here, but... straight Bellucci's? Her ear is just a mess. And this is again, this is kind of more of a chronic inflammatory issue I think. Yeah. So - What's that? Yeah. Let's have a foot plate? So she has an epithelial pearl, which has formed on the surface of her eardrum. Right here. And the issue is they sometimes... And it just usually scoops right out. Let's have a pair of Bellucci's. It's usually where, just skin gets trapped under the normal epithelium, but they can sometimes grow quite big. A lot of times they will just rupture on their own and come out or you can kind of take them out in clinic. Let's have a pair of Bellucci's to the left. Okay. All right. Let's do that. Now - down here we need to elevate a little bit more, we're going to have to get this. She's just got... Let's have a round knife now. She just, her whole ear has all this just inflammation. Hopefully, I think if we can get this stuff to settle down, this will heal up fine. Again, we're elevating here. I'm elevating inferiorly because I need to be able to get my graft underneath this canal skin here. Ultimately. So we're going to kind of push this down, there's annulus there. So I will - we will be putting our graft and allowing it to come way up underneath all this. The next thing we need to do is figure out... I'm going to use some cartilage to actually help graft her eardrum. And I'm going to also take some cartilage to fix this part of the ear canal wall.

CHAPTER 6

Let's have a pair of pickups now. That was a pretty big incision. And I'm going to use a little bit of symbol cartilage. Double-pronged skin hook. And a sponge, please. If you will hold that. Now a Bovie. I got it. Now a pair of iris scissors. Cartilage is really brittle too, it's interesting. Yeah. Kind of unusually brittle. I'll set that there. And then we'll just kind of separate this. Did y'all already open that graft? Okay, they can open it and have it on the table ready to go. So I'm going to take a second piece, this is I'm going to use to actually help rebuild the - reconstruct the eardrum. Cartilage... There we go. All right, now, can I have a pair of smooth forceps and that tongue blade? Now a self-retaining retractor back.

We're going to thin these down, just get rid of all this extra tissue. Make little plates out of this. Yeah, I'm just getting all the perichondrium off and any irregular surfaces, kind of make it more flattened out. And you can trim it to try to take out some of the curvature of it so it's not bowing too much. This may be my front piece. Okay, so now can I have the other big piece of cartilage? That bigger piece of cartilage. Okay, let's see what we can do with this. Can I have a large round knife? I can use this perichondrium, I think. Yeah, on bigger pieces, it comes away pretty well. You just have to get it started. Once you get it started in the right plane, then it usually does pretty well. I like to take this off, it just allows me to shape the cartilage better. And we can - we probably will use this. We can probably use this perichondrium for some other little coverage or graft or something. And I hope this is going to be big enough. No. The beauty of cartilage is that it takes so well, everywhere pretty much. Do we have a fascia press? Can we have that? And I'll take that up. I don't want it - it's kind of tearing my cartilage right there, which I don't want it to do that. Let's have an 11 blade now. One second. Okay, fascia press? And we'll just keep this in a press for a second. I'm going to have to leave a little bit of that on there, I think. So that is probably through and through, yeah. Can I have a... Can I have a pair of scissors now? Let's see if this is going to work. Probably will work pretty well. Something like... Like that. Suction? Can I have an irrigating syringe? What's that? So now, we've got our cartilage all, pieces cut. I'm kind of looking at - table towards me. The fit of the canal wall cartilage to kind of see how that's going to fit in here, and if we need to make any kind of adjustments or anything to the shape of it, sometimes you have to kind of play around with this a little bit to get it to conform the way you want. It probably fits better - It's going to fit better like that or maybe like this. I think that's probably the best though, the best fit for it. Something like that. And can I have - Whitney can I - I am going to need a drill. I don't need a suction irrigator and all that, but I need a drill with a 2-mm diamond burr.

CHAPTER 7

Yeah, that's just all kind of eroded. Can I have that 11 blade for a second? I mean I've kind of beveled these edges down a little bit so that they'll sort of sit more flush with the canal wall. That one's okay. So what I'm going to do now, to try to get this cartilage to seat better, we're going to create some little grooves in the posterior canal wall bone. Yeah, it just needs - you got to make some little slots or grooves to kind of anchor it. Okay, water on. There. Let me have an 11 blade. There. Alright, so that's that. That fits in very nicely. Now. Can I have an irrigating syringe again and a 7 or a - Yeah, a 7-suction. Now we'll do our - we're going to do our - put our graft in. And one thing I'm going to do is I'm going to use those little perichondrial pieces in just a minute to kind of anchor this. You gotta kind of anchored that graft a little bit better in place. Rinsing the ear really well, again, bacteria, kind of dilute it out. Also we want to make sure we get out any skin, little bits of skin or bone dust or anything like that. Okay, those little perichondrial pieces we had earlier. And what we can do with these, is actually kind of put this down here, and sort of anchor this in place. Up. And we'll just lay that down. Can I have a Rosen? Oh, and a 3-suction. Yep. And a 3-suction? Yep. Actually, that's a nice piece. So this, we'll just kind of to kind of support this, and hold it in place. Now, that other small piece we'll take. And gonna do the same thing with this Up on the superior aspect of it. Bring this up more laterally. All right now, can I have a... A Gimmick, please? So the next phase is we need to get this flap up a little bit. Kind of like getting our temporomeatal flap completely up, and I'm going to take the packing now. Yes, packing, please.

CHAPTER 8

Okay, sorry. All right. Can we have some - yes, please. And make sure it's pressed out though. No, let's have a - do you have a dry sponge? So sometimes I have to press these out. Press them out a little bit more. Little bit more. Yep. I don't really feel... It's weird, I don't feel... She doesn't really have that much of a eustachian tube opening. I wonder if that's... Just the opening of the eustachian tube, but I don't - I mean it really, there's nothing there. That makes me wonder is - you know, is this more - is that part of the issue? Is this like a chronic ventilation problem? It should be right here. But there is nothing, I mean she really doesn't have much of an opening. I cannot, I can't feel her eustachian tube at all. Which of course then you wonder, should we put a tube in her ear? Of course, she doesn't want that, she wants her eardrum healed. That's weird. More packing. So this is Gelfoam, and it is soaked with a little bit of Kenalog 40, just because of all the inflammation in her ear. I would like a little bit of steroid on this. One second. Do you have a dura- a lung Crabtree I could have for a moment? I like that, I like this to get it up under the malleus. Packing? Yep, MeroGel? MeroGel is nice because I can suction it. Now a Rosen. And I may - yep. Yeah, correct. And then, this just is kind of a free graft that goes, it sits on top of this Gelfoam. The Gelfoam kind of pushes it up against the undersurface of the TM. Like so. Small piece of Gelfoam, like real tiny. It is tending to curve a little bit down up top here, so I'm, or actually do you have a little piece of MeroGel? So I'll use a little MeroGel, just to kind of push it out. MeroGel? Perfect. There. Okay, now, the other thing, the next phase is we have got to get our graft under here. So now the - do you have one more? That's actually okay, let's have the graft now. This should be interesting. Let's have that graft, the synthetic graft. So now we are going to trim our graft. And it's going to be a fairly good-sized graft. And we can keep some of these extra pieces, just in case. Because this doesn't have any kind of backing on it or anything, right? Scott? It actually feels pretty good though. And I am going to make a little notch, I'm going to kind of do this a little bit like a - a lateral. Even though it is a medial graft. Okay, can I have now a pair of alligator forceps? Can I have a sharp Rosen? Yes, please. This is kind of nice to work with it, so far. So we're going to actually tuck this up under here. Yeah, it's nice. And this is our porcine connective tissue graft. And the one thing we also need to do is get this up under the malleus handle. It's very important to do that in order to prevent this graft from lateralizing. And so I actually made a small notch in this graft. And we are going to tuck this part. Can I have a piece of MeroGel for a second? MeroGel? Please? I'm going to use this just to blot some fluid. And I'm going to remove it. Until we can get this thing up underneath here. And now my graft, I am pulling this up under the malleus. And we're going to have to do a little bit of playing around with this in a minute just to get it smoothed out the way we want. I now have this graft under. And I am going to bring this back leaflet over. This way. Going to unfurl that. I'm going to put this up here. This graft is, you know, bigger than it needs to be, but so we have some room to play around with it. And then the front leaflet will also come over. I'm going to bring this up a little bit. Make sure that this is kind of coming up onto the canal wall a little bit here. And then bring this over to cover the top of the malleus. We actually have really good coverage of all these areas. And now that the graft is in place, we've got this front leaflet - coming over the - from - here's the - I made a small cut in the top of that graft so I could get it around the malleus handle, and then this is the front leaflet of that cut we've kind of folded back. And that's what we would do, kind of typically when you do a lateral graft you - you make those cuts. I'm going to tuck this way anterior as far as I can. My cartilage graft is underneath there. And that's laying down nicely. Kind of flatten this out some. So we have good coverage there. Then I'm going to bring this skin back into its normal position, which will cover up here, kind of help epithelialize these grafts up here. And then inferiorly, we need to make sure our graft is laying where we want it to. We've tucked this far... We've tucked our graft anterior, underneath this drum remnant. And then we're going to allow this to actually come up on to the canal wall a little bit. And then we'll bring this skin flap back to its normal position as well. Can I have a Gimmick now, please? And I'm going to need a rolled up piece of Gelfoam, like a cigar roll. And then we'll bring all this back. Mind the tremor there. There we go. This is a rolled up piece of Gelfoam, just to push into the anterior sulcus to just kind of hold everything snugly there. Now, small pieces of Gelfoam pressed out, please. Hopefully, I don't know how - we'll have to see how this stuff, you know if it contracts well, or... I'm not sure. It will be interesting to see how it heals up. Okay, Gelfoam? Good. My only concern is with all this mucosalization, you know, you - hopefully she will epithelialize okay. There's a possibility this whole graft now will, will have delayed healing and just kind of be mucosalized, which in somebody who's had chronic issues like that, that sometimes happens. Okay, continue packing. Okay. More packing. Keep it coming. We'll see. I like the way the canal wall came out, that looks good. Yeah. The other thing that's important is putting some packing on the backside of where this cartilage graft is to support it. Yeah, you want to kind of put a little bridge of Gelfoam back here just to kind of buttress, you know, push up against it, and it just gives it some stability. Right, I think you would have to push it in there pretty hard to get that to happen, but... Big pieces.

CHAPTER 9

Okay. Take that. Okay, a stitch? I know, hold that ear down, Chelsea, just like that.